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Monday, October 30, 2006

Excellent article in today's New York Times on child slavery in Africa and other developing countries. It highlights the issue also from the perspective of families frequently selling their children into slavery in order to survive.

The BMJ reports that Germany plans to penalise cancer patients who failed to undergo regular screening. That's very much in line with the country's policy to charge dental patients higher rates who failed to have regular check-ups.The argument is obviously that these patients had a good chance to prevent getting seriously ill, yet they chose not to do so by omitting to undergo screening. Timely detection of early stage cancer and early intervention dramatically reduce serious illness and death.Invariably such a drastic policy has its critics. Hazel Thornton writes on BMJ.com that such a policy 'intrudes on an individual`s right to refuse an imperfect intervention that can result in false negative and false positive diagnoses; can lead to gross over-treatment; to psychological harm and false categorisation as `cancer patient`.'Thornton's argument misses the obvious point that the harmful effects of some false negative and false positive diagnoses are by far outweighed by the majority of correct diagnoses resulting into early treatment. Of course, patients are entitled to refuse such testing, but surely if they do, it is not unreasonable to ask them to compensate other tax payers for the additional cost their behaviour is causing.

post scriptum: Given that this blog has no discussion forum, I have decided to post the below reply to this blog (with permission by the person posting it).

Udo,

Your post on screening seem to imply that it is always cost-effective. Yet I haven't seen any numbers from you other than vague statements of how risks can justify the benefits. Have you done any calculations? You have to factor in that

1) cost of screening of millions of people

2) cost of false positives and invasive tests

3) cost of overdiagnosis - i.e. cost of treatment of people whose cancer wouldn't have caused any problems in their lifetime

4) cost of longer treatment for aggressive cases that are not helped by the treatment other than increase the time after diagnosis (at the expense of time before) (read up on lead-time bias if you don't understand what I am talking about here).

Do you know statistics at least a little bit? Do you understand the difference between relative risk and absolute risk reduction?Do you have a clue about how many people need to be tested for one person to benefit? Do you know that for every person whose life is prolonged, several are treated unnecessarily and may have life shortened as a result?

Do you know that you have a higher chance of being diagnised with some cancers if you are screened? Are you aware that because of false positives and overdiagnosis lots of popular screenings are not even remotely cost-effective because cost of screening+cost of treatment for overdiagnosed cases+ cost of false positives is significantly greater than the savings on less treatment for few?

You can take mammograms as one example and do your math. You can use numbers from this article ( http://www.bmj.com/cgi/content/abstract/330/7497/936) which many consider overly optimistic - the mortality reduction listed in this article is way higher that what USPSTF used and about 4 times more optimistic than more recent Cochrane review (from October this year). If German government is using cost to justify their plans - they are way off. Insurance companies had to be forced to pay for screening because unlike German government they can do their math.

The balance of benefit and harm for most screening tests is not as clear cut as you think it is. Few peolple benefit tremendously from it, but some are hurt. It'd be nice to have some proof of cost effectiveness before you start penalizing people for not doing it.

Tuesday, October 24, 2006

I have finally made a decision re PETA's request to support their quest to have 'gay sheep' research at Oregon State University stopped. Here's the background of the story. On October 19, 2006 I wrote this letter to the Principal of the institution...

Dear Dr Ray:

PETA contacted me some time ago with regard to research undertaken by your Dr Roselli and colleagues. This, I assume, is primarily due tothe fact that I am reasonably well-known in the field of bioethics andalso perhaps due to my outspoken views on biological research onsexual orientation.

I have since contacted Dr Roselli with questions pertaining to hisresearch. He chose not to respond. Assuming that his mail bag hasgrown a bit since PETA's campaign, I won't fault him for that.

Having said that, based on my understanding of his research, he seemsinterested in questions pertaining to the sexual orientation (andtheir alterability) of higher mammals, with the main focus of hisresearch being sheep.

I should be honest, unless I misunderstand the research in question, Ithink Dr Roselli's serves no health related purpose. Once hisquestions have been answered one way or another, there are no healthbenefits flowing either to sheep or any other higher mammals,including humans. I do think that it is highly ethically questionablewhether it is acceptable to subject higher mammals to pain andsuffering in the course of research the outcome of which has not thewell-being and health of higher mammals in mind.

Equally, while I do not subscribe to the view that Dr Roselli himselfis driven by any kind of homophobic agenda, I cannot see how anyresearch results he might come up with would not be seized upon bypeople with precisely such an agenda.

This brings me to the question of whether or not such research oughtto be undertaken. For better or worse, I have spend five yearsworking in a leading Southern African medical school. Considering thehealth problems the world is facing, it seems remarkable to me that aleading scientist such as Dr Roselli should concern himself withfrankly irrelevant questions. That the pursuit of these researchquestions should result into pain, suffering and death for highermammals makes his endeavour all the more questionable.

Monday, October 23, 2006

What a brilliant idea! South Africa'sMinister for Health (Prevention), Manto Tshabalala-Msimang, has finally got her own fan club, a website calling for her to be sacked ASAP. Tshabalala-Msimang, dutifully carrying out the painfully idiotic views of her boss, the country's President, Thabo Mbeki (who thinks HIV is not the cause of AIDS, and that there is no AIDS epidemic in his country), should have been sacked a long time ago, along with Thabo Mbeki.So, make sure to leave your vote and support the campaign to get Tshabalala-Msimang sacked.

Thursday, October 19, 2006

Alan Johnson, the Education Secretary, went on public record demanding that faith schools become less exclusive and take in up to 25% pupils coming from other faiths or none. Funny man he is. Can't he see that the whole point of faith schools is segregation and the fostering of secterianism. Otherwise we would have only public schools in which all pupils received the same education. Faith at best entered the school by way of explaining what faiths are out there to adopt by those inclined to believe in a good omniscient 'God', 'Allah' or some creation like em.Faith schools primary objective is to indoctrinate kids to ensure they stick with a particular religious ideology throughout their lives, thereby guaranteeing to the leaders of these religions influence in public life that they wouldn't have if they had to rely on the power of their arguments.It is somewhat amusing that we have at this point in time a big debate about Muslim teachers wearing the Ninja turtle outfit during class, while the much larger moral evil is the very existence of faith schools. They clearly are designed to rob future generations of the opportunity to enter the world of adulthood without having been indoctrinated for many many years. A good colleague of mine calls this 'child abuse'.

Monday, October 16, 2006

So it's 'amtlich', Madonna is trying to adopt a boy in Malawi. Should she be allowed to do so? A whole bunch of professional do-gooders believe she shouldn't. Mostly children's charities operating in Malawi and the perhaps inescapable church groups. They're currently going to court in Malawai to prevent the adoption from going ahead.

This leads to various interesting questions, chief among them whether Madonna's course of action was the best she could have taken under the circumstances. This question is being asked by lots of commentators and the opinion of most is that Madonna is doing something wrong. Their main rationale is that she could help more orphans in Malawai if she sponsored instead schools or sponsored a much larger number of children thru a charity.

The critics clearly have a point here. However, that taking legal action in order to prevent the adoption from going ahead is the right response is doubtful. Imagine if it became a universal rule that unless you undertook a particular course of altruistic action some charity or other would sue you and demand that you do what it believes is the best thing (usually probably sponsor the charity and its staff...). In Madonna's case, it seems somewhat clear that everyone is better off (the child will have a fairly comfortable upbringing together with Madonna's other pampered off-spring; Madonna got the additional child that she wanted, the kid's biological father is supportive because he doesn't have to worry anylonger abbout the child's welfare).

So, while we're probably entitled to snigger at Madonna's action, clearly the actual outcome is desireable. There certainly is no reason to take legal action to prevent the adoption from going ahead.

A second question that puzzles me a bit is this: If the charities are really so concerned about children in need, is it acceptable to put a lot of stress on a little child in order to pursue a legal (and, let's face it, political) case against Madonna. After all, while the kid is getting used to seeing Madonna and her other half as his parents, there are these children's charities trying to bring this process to an end. How would the kid feel if they succeeded? Surely it's not better off returning to an impoverished African orphanage. The point I am trying to make is that the legal case is surely not in the child's best interest, quite to the contrary.

This, again, makes me wonder about the charities' motives.

I can't help thinking that this adoption is also a fairly powerfulstatement against racism...

Saturday, October 07, 2006

While I whinge (just below) about my stolen bike... one should never forget, that everything in this regard is relative. JUst check out the most recent (official, as in: not entirely credible) crime stats from the rainbow nation (aka South Africa).Here's Cape Town's ex Archbishop Desmond Tutu's take on this matter.

Check it out ... I got myself a new bike... yet again. It's the white Diamondback. The black Trek 4300 is the most recently stolen one. Beautiful bike... had it less than a year. - There is something odd about the UK and my bikes. I have lived over the years in quite a number of different countries, some of which with a substantially higher crime rate than the UK (think Joburg, South Africa). Thing is though, I have nowhere lost as many bicycles to theft as I have in the UK. It's truly belief defying. I guess during the last 18 months or so I lost bikes worth close to 2000 GBP to theft.What particulary irks me is that there doesn't seem to be any culture of watching out for one's neighbours in this country. Most recently I had a bike stolen outside Tesco's in Argyle street. Now, that's an innercity food store. There's is substantial 24 hour pedestrian traffic. Yet, someone cutting thru my chain in order to steal the bike while I did my food shopping, didn't motivate any of the passers-by to call the police or even the security guard responsible for ensuring nobody steals Tesco's yoghurts. Not that the company seems to care about the perils its customers vehicles are in while their owners are shopping at Tesco's.